Nursing 2000 Exam 3 Cedarville University
Questions and Answers
What are the layers of the skin? - ANS-epidermis and dermis
What is the layer of fat under the skin called? - ANS-adipose tissue (hypodermis)
What are the functions of the skin? - ANS-protection, thermoregulation, sensing
environment
What is the largest organ of the body? - ANS-skin
What the the weight percentage of the skin? - ANS-15%
What are the age-related changes of the skin? - ANS-Decreased elasticity
Decreased collagen
Thinning
Slow wound healing
Decreased subcutaneous padding
True or false: as nurses we own the skin - ANS-true
A nurse is _________ of ___________ the skin - ANS-in charge, protecting
What are the two things a nurse should look for when assessing the skin of an admitted
patient? - ANS-Look extra to verify any pre-admitted hospital infections/wounds
Identify patients that are at risk for skin integrity
What is the key to prevention of a pressure ulcer? - ANS-make sure you do not keep
pressure on one area for too long
What are other precautions that should be taken to maintain the skin integrity of a
patient? - ANS-Patient is well-hydrated
Patient is well-nourished
True or false: there is only one type of tape for patients. Therefore, finding the right kind
of tape is not a concern. - ANS-false
True or false: it is important to know what medication your patient is on - ANS-true
What are the three factors that contribute to pressure injuries? - ANS-Intensity
Duration
,Tissue tolerance
How does intensity affect blood flow? - ANS-Too much pressure can disrupt the
capillary bed leading to tissue ischemia
What does intensity determine? - ANS-extent of interruption of blood supply
The more intense the pressure, the greater what? - ANS-ischemia
The greater ischemia the greater what? - ANS-tissue damage
Where does intensity increase? - ANS-over bony prominences
How can the degree of poor tissue perfusion be estimated? - ANS-color changes in the
epidermis
Shows erythema or redness, indicates vasodilation - ANS-hyperemia
What causes hyperemia? - ANS-Pressure is released and a rush of blood flow to the
area trying to counteract the ischemia
an attempt to overcome ischemic spell - ANS-blanching ischemia
What should a nurse see when they press their finger on a patients palm to test for
blanching? - ANS-Flesh color-white-flesh color
there is damage to the tissue, does not have a vascular flow and there is also capillary
damage - ANS-non-blanching erythema
After a test for non-blanching, what should a nurse see? - ANS-red-red (after pressing
the skin stays red)
True or false: skin that is damaged could be lighter or darker than other areas of normal
skin - ANS-true
What does hot to the touch skin indicate? - ANS-inflammation and a new injury
What will the touch feel like to an older injury of the skin? - ANS-cool
True or false: a nurse should palpate the the skin after assessing it - ANS-true
What will new skin feel like? - ANS-firm
What will taunt skin be like? - ANS-stretchy
What does old skin act like? - ANS-boggy (spongyness)
, What is bogginess? - ANS-hanging out
More than ____ many hours can lead to significant tissue perfusion - ANS-2
What causes this duration to lessen? - ANS-poor nutrition and health
Does being on a ventilator affect the duration time too? - ANS-yes
Duration is ______ - ANS-key
What are some factors that decrease tissue tolerance? - ANS-Malnourishment
Poor hydration
Older age
Stage of life (infant, premature babies, newborns)
Poor hygiene
Immobility
Medical condition
What are some medical conditions that could decrease tissue tolerance? - ANS-
decreased blood flow
slow wound healing
CDS
Peripheral vascular disease
spinal cord injuries
A nurses finds out that a patient stepped on a nail two day before coming to the doctor.
The nurse assessed the area of the skin and during palpation the patient did not flench
when she touched the tender wound. What does the patient have? - ANS-altered
sensation
A patient with altered sensation is at risk for what? - ANS-ulcer development (diabetes
are at the greatest risk for this)
inability to independently change position - ANS-Impaired mobility
inability to effectively communicate what you need - ANS-Change in LOC
What are all of the at risk factors for ulcer development? - ANS-Altered sensation
Impaired mobility
Change in LOC
Shear
Friction
Moisture
What does LOC stand for? - ANS-level of consciousness
Questions and Answers
What are the layers of the skin? - ANS-epidermis and dermis
What is the layer of fat under the skin called? - ANS-adipose tissue (hypodermis)
What are the functions of the skin? - ANS-protection, thermoregulation, sensing
environment
What is the largest organ of the body? - ANS-skin
What the the weight percentage of the skin? - ANS-15%
What are the age-related changes of the skin? - ANS-Decreased elasticity
Decreased collagen
Thinning
Slow wound healing
Decreased subcutaneous padding
True or false: as nurses we own the skin - ANS-true
A nurse is _________ of ___________ the skin - ANS-in charge, protecting
What are the two things a nurse should look for when assessing the skin of an admitted
patient? - ANS-Look extra to verify any pre-admitted hospital infections/wounds
Identify patients that are at risk for skin integrity
What is the key to prevention of a pressure ulcer? - ANS-make sure you do not keep
pressure on one area for too long
What are other precautions that should be taken to maintain the skin integrity of a
patient? - ANS-Patient is well-hydrated
Patient is well-nourished
True or false: there is only one type of tape for patients. Therefore, finding the right kind
of tape is not a concern. - ANS-false
True or false: it is important to know what medication your patient is on - ANS-true
What are the three factors that contribute to pressure injuries? - ANS-Intensity
Duration
,Tissue tolerance
How does intensity affect blood flow? - ANS-Too much pressure can disrupt the
capillary bed leading to tissue ischemia
What does intensity determine? - ANS-extent of interruption of blood supply
The more intense the pressure, the greater what? - ANS-ischemia
The greater ischemia the greater what? - ANS-tissue damage
Where does intensity increase? - ANS-over bony prominences
How can the degree of poor tissue perfusion be estimated? - ANS-color changes in the
epidermis
Shows erythema or redness, indicates vasodilation - ANS-hyperemia
What causes hyperemia? - ANS-Pressure is released and a rush of blood flow to the
area trying to counteract the ischemia
an attempt to overcome ischemic spell - ANS-blanching ischemia
What should a nurse see when they press their finger on a patients palm to test for
blanching? - ANS-Flesh color-white-flesh color
there is damage to the tissue, does not have a vascular flow and there is also capillary
damage - ANS-non-blanching erythema
After a test for non-blanching, what should a nurse see? - ANS-red-red (after pressing
the skin stays red)
True or false: skin that is damaged could be lighter or darker than other areas of normal
skin - ANS-true
What does hot to the touch skin indicate? - ANS-inflammation and a new injury
What will the touch feel like to an older injury of the skin? - ANS-cool
True or false: a nurse should palpate the the skin after assessing it - ANS-true
What will new skin feel like? - ANS-firm
What will taunt skin be like? - ANS-stretchy
What does old skin act like? - ANS-boggy (spongyness)
, What is bogginess? - ANS-hanging out
More than ____ many hours can lead to significant tissue perfusion - ANS-2
What causes this duration to lessen? - ANS-poor nutrition and health
Does being on a ventilator affect the duration time too? - ANS-yes
Duration is ______ - ANS-key
What are some factors that decrease tissue tolerance? - ANS-Malnourishment
Poor hydration
Older age
Stage of life (infant, premature babies, newborns)
Poor hygiene
Immobility
Medical condition
What are some medical conditions that could decrease tissue tolerance? - ANS-
decreased blood flow
slow wound healing
CDS
Peripheral vascular disease
spinal cord injuries
A nurses finds out that a patient stepped on a nail two day before coming to the doctor.
The nurse assessed the area of the skin and during palpation the patient did not flench
when she touched the tender wound. What does the patient have? - ANS-altered
sensation
A patient with altered sensation is at risk for what? - ANS-ulcer development (diabetes
are at the greatest risk for this)
inability to independently change position - ANS-Impaired mobility
inability to effectively communicate what you need - ANS-Change in LOC
What are all of the at risk factors for ulcer development? - ANS-Altered sensation
Impaired mobility
Change in LOC
Shear
Friction
Moisture
What does LOC stand for? - ANS-level of consciousness
